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Archive for the ‘injectable fillers’ Category

Nanofat Grafting

Sunday, May 28th, 2017

 

Injectable fillers are the most common method used today for a wide variety of facial volumizing effects. Ideal for patients that want an immediate result that avoids surgery, the selection of almost twenty different fillers provides a filler type for every patient’s needs. Despite these advantages injectable fillers have one major downside…lack or persistence. Despite manufacturer’s efforts to improve their longevity, permanent injectable fillers that have a good safety profile are not on the near horizon.

Fat grafting offers an injectable material that does have the potential for a permanent augmentation effect. Its problem, however, despite this potential is that it is wildly unpredictable. Different intraoperative processing methods and harvest sites have been used but the concept of optimizing fat cell survival remains not completely worked out. In addition, traditional fat grafting creates a thicker more putty like material which does not lend itself well to a smooth linear  injection like that of synthetic injectable fillers.

An alternative fat grafting method is that of micro- or nanofat grafting. In this technique the fat graft is micronized or emulsified into a much more liquid mixture. This can be done by machine or manual technique. The intent here is not too focus on fat cell survival but to create an autologous scaffold by shearing the fat into small particles. This not only adds volume by injection but provides a bio-scaffold framework onto which new tissue ingrowth may occur. If PRP (platelet-rich plasma) is added to the nanofat graft a potent autologous regenerative matrix is created that far surpasses the biologic response to a synthetic injectable filler.

The physical benefit of nonfat injections are that they act like injectable fillers. Their emulsified nature allows them to be injected from very superficially into or just under the dermis or into deeper tissue planes. Such particulated fat grafting has been shown to result in improved skin quality that is maintained out to six months to year

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Fillers to the Nose

Thursday, May 4th, 2017

 

The use of injectable fillers in the face has expanded tremendously over the past decade. What was once viewed as off limits to place fillers has now become commonplace. This is particularly relevant to the nose whose small and tight tissues was historically felt to be an ill advised place for injecting fillers.

But today patients interested in augmentative rhinoplasty or in rhinoplasty revision seek injectable fillers as an immediate and non-surgical approach to their concerns. Building up the bridge in particular can be a very rewarding change that can be achieved on minutes and can last six months or longer. Small imperfections or indentations after a rhinoplasty can be quickly corrected with spot injections of very small volumes.

In the May 2017 issue of the journal Plastic and Reconstructive Surgery a paper was published entitled ‘Facial Danger Zones: Techniques to Maximize Safety during Soft Tissue Filler Injections’.  In this well written paper the authors discuss their preferred injection techniques based on the facial dangers zones (key locations of arteries and veins) to minimize the risks of vascular complications…which can be catastrophic.

One area of relevance from this paper to this post is that of the nose. For treating the nose, they advocate injecting deep down at the periosteum and perichondrium level. This is because the blood supply to the soft tissues of the nose its very superficial and runs just under the skin. Deep injections avoids injuring and inadvertently infusing the vessels. When injecting compression of the dorsal nasal and angular arteries should be done as well. The nose should be injected serially with 10 to 15 minutes between each injections with massaging of the nose between each serial injection. For the nasal tip and ala, serial punctures with very small volumes should be done to inadvertently making a bulbous tip.

The one exclusion for nasal injections is in the previous rhinoplasty patient, particularly one that has implants or grafts on the dorsal of the nose. Scar tissue and the distortion of the tissue planes makes the risk of vascular compromise much higher.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Juvederm Vollure XC

Friday, March 24th, 2017

 

With now over 25 synthetic injectable fillers available in the U.S., one would think there is little need for further filler products. But the ability to modify hyaluronic acid filler structures to create different aesthetic effects assures that more such filler products will continue to become available.

Juvederm Vollure XC Dr Barry Eppley IndianapolisJuvederm Vollure XC has just become FDA-approved for injection into moderate to deep facial wrinkles such as the nasolabial folds. It is formulated with proprietary Vycross technology, which blends different molecular weights of hyaluronic acid, contributing to the filler’s long duration. Juvederm Vollure XC will be available in the United States in April 2017. This specific filler is not new in other parts of the world as it was first approved in Europe under the name of Juvederm Volift in 2013.

In the clinical trial that led to its approval, 59% of patients saw improvement in moderate to severe nasolabial folds for up to 18 months, with 82% of patients saying they were very satisfied at 6 months and 68% at 18 months. With a duration that has been shown to last up to 18 months from the initial or touch-up injection in a majority of patients, this is the longest lasting result shown in a clinical study in the nasolabial folds to date.

Like all injectable fillers it has typical side effects such as swelling, tenderness, bruising, firmness lumps/bumps, redness, pain, discoloration, and itching. Other than lumps of the material these side effects resolved within one week after injection.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review – Restylane ReFyne and Restylane DeFyne

Sunday, March 5th, 2017

 

With over 25 synthetic injectable fillers on the US market it can be argued that how may more do we really need. But each new injectable filler offers some advantage and thus there is room for more. These growing number of injectable fillers has led to the concept of a toolkit of injectable treatments that allows customized use for specific facial aging indications  and applications.

Restylane Refyne and Restylane Defyne Dr Barry Eppley IndianapolisThe most recently approved filler is Restylane Refyne and Restylane DeFyne.  These have been FDA approved for the treatment of nasolabial folds. The main difference with these Restylane products and other hyaluronic acid fillers in in their inherent flexibility due to the proprietary XpresHAn technology. (X = cross-linking, Pres = pressing gels through mesh for calibration, HA = hyaluronic acid) This allows facial expressions (smiling, frowning, etc) to not feel stiff and more natural due to the flexibility of the filler material.  While new to the U.S. the product has been used in Europe for years under the name of  Emervel.

Restylane Refyne is the most flexible and provides support for moderate lines while Restylane Defyne is less flexible and is intended to support deeper lines. Their advantage amongs injectable fillers is their ‘Natural Expression in Motion’. Most patients treated felt that their facial expressions were unaffected and the location of the filler was not detectable.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Jaw Angle Augmentation Fillers vs Implant

Monday, December 26th, 2016

 

Augmentation of the facial skeleton has historically been done through the placement of preformed implants. The past decade has seen the emergence of a variety of injectable materials to create soft tissue volume augmentation. These have included a large number of synthetic fillers as well as autologous fat. As their use has become more common and pervasive throughout aesthetic surgery, the injectable approach has been applied to every conceivable aesthetic facial need including augmentation of the bony cheeks, chin and jaw angles.

An injectable filler can be used for jaw angle augmentation. It does not usually produce the same result as a well selected jaw angle implant as it can not create angularity and sharper definition with the push of a soft material like fillers or fat. Thus injectable fillers for jaw angle augmentation is often done as a test or trial or are sometimes performed as a convenient opportunity at the time of other facial surgery using fat injections.

jaw-angle-implants-vs-injectable-fillers-dr-barry-eppley-indianapolisBut beyond that of a trial, the use of injectable fillers as a long-term method of jaw angle augmentation is compromised by economic issues. When one compares the volume of an injectable filler to an actual jaw angle implant (in this picture 1.5cc of Radiesse to a medium vertical lengthening jaw angle implant) the tremendous discrepancy in its volume/size can be seen. By comparing weights alone it can be seen that it would take more than 5cc to 7cc of a filler to match the volume created by an implant.

Because of their long-term cost issues, injectable fillers are a short-term approach to jaw angle augmentation. This is not only because they are not permanent but the sheer cost of trying to replicate an initial jaw angle implant effect.

Dr. Barry Eppley

Indianapolis, Indiana

Product Review: Allofill Injectable Filler

Saturday, October 8th, 2016

There have been numerous injectable fillers for facial use that have become commercially available since 2002 when the product concept was introduced. All of these fillers have been of the synthetic variety containing mainly resorbable and a few non-resorbable materials. While these are convenient off-the-shelf products, almost all only offer a temporary augmentation effect.

Fat grafting as become a popular form of facial voluminization as it offers the potential for better long-term augmentation. It achieves that effect as it is harvested from the patient and such autologous fat cells can potentially survive the transfer process. But it is a surgical procedure and not a ready made product.

allofillAllofill is the newest member of the off-the-shelf injectable filler products. While premade it differs because it is composed of fat…specifically cadaveric fat. Like many other alloplastic (cadaveric-derived) graft materials, this is a tissue bank-based material. It is derived from donated human adipose tissue intended for transplantation. Its biologic supposition is that, like naturally harvested fat, it provides a tissue scaffold/matrix which can become ingrown by blood vessels and fibroblasts to create new natural tissue. The difference is that natural fat has live adipocytes while Allofill does not.

In theory, Allofill offers the convenience of a premade injectable filler with the long-lasting results of fat grafting. The former is absolutely true, the latter awaits long-term clinical studies to substantiate. It is available in a 3cc syringe which is two to three more than all other injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Lower Blepharoplasty for Fat Injection Removal

Wednesday, September 7th, 2016

 

Treatment of tear trough and under eye hollows has been revolutionized by the use of injection materials. Using either resorbable injectable fillers or fat taken from the patient, injection under the eyes can fill out sunken areas creating a rejuvenated appearance. Although there are advocates for either synthetic fillers and fat, both materials can have good success in the lower periorbital region.

While many patients have good improvement in their tear troughs and under eye hollows with injections, not all patients do. The under eye area is the most technique sensitive area of the face for any type of injection. The thin tissues of the lower eyelid reveal any asymmetries and irregularities of the injected material. This may not be apparent for several days or weeks when any swelling has subsided. In some cases too much volume ends up creating the appearance of lower eyelid ‘bags’ which the patient is swelling and will go away on its own.

Solving these lower eyelid injection materials is fairly straightforward with hyaluronic-based injectable fillers. Enzymatic digestion with hyaluronidase injections can rapidly remove any excess material. But this is not the case with other types of injectable fillers (e.g. Radiesse) and fat injections for which no reversal injections exist.

lower-blepharoplasty-for-injected-fat-removal-dr-barry-eppley-indianapolislower-blepharoplasty-injected-fat-extraction-dr-barry-eppley-indianapolisSuch materials can only be removed by direct excision through an open eyelid approach. By exposing the deeper eyelid tissues under the skin any problematic material, such as fat, can be directly removed. Injected fat looks different than lower eyelid compartmental fat and is fairly easily identified by its linear horizontal orientation. It can be carefully lifted out from the tissues in which it is embedded.

For those patients so afflicted with undereye contour problems from injected fat or particulated synthetic fillers, excision is the only effective treatment. Like all lower blepharoplasty procedures the subciliary and lateral canthal incision usually heal in an inconspicuous fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Jaw Angle Implants vs Injectable Fillers Volume Effects

Saturday, July 2nd, 2016

 

Jaw angle implants have become more recently recognized as an essential part of jawline augmentation. While much focus has historically been on the front protruding part of the jaw through chin augmentation, it is now recognized that the chin represents just a part of the total lower facial effect.

While jaw angle implants have been around for several decades they have been limited to an implant style that only provides width to the ramus of the mandible. While this has a beneficial role in some patients, many jaw angle deficiencies are as much vertical if not more so than just width. Lengthening the jaw angle and creating a more obvious angularity to the back part of the lower jaw has some major aesthetic benefits.  This has been remedied today with more vertical lengthening jaw angle implants. Injectable fillers have also been used to create this effect with variable success. But it is an accepted ‘trial’ method for some patients to determine if such changes would be perceived as beneficial.

When it comes to jaw angle augmentation does an injectable filler really create the same effect as an implant? And if it does how does it compare volumetrically?How does the volume of an injectable filler compared to the displacement effect caused by a solid implant? In other words, how much injectable filler does it take to create the same effect as that of an implant?

Comparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would be equal to the volume of the implant. Using newer vertical lengthening jaw angle implants of its three available sizes, their weights in grams and volume displacement were as follows:

JAW ANGLE IMPLANTS

Small              3.65 grams     1.6 ml

Medium        7.54 grams     2.7 ml

Large            14.98 grams    4.2 ml

Jaw Angle Implants vs. Injectable Fillers Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to jaw angle implants can be directly done. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to less than half of a small jaw angle implant. Larger jaw angle implants more directly compare to more than two to three 1.5cc syringes of Radiesse.

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison Between Nasal Implants and Injectable Fillers

Thursday, June 16th, 2016

 

Augmentation of the nose is a frequent element in many rhinoplasty procedures. While the use of locally harvested cartilage grafts works in may cases, more significant augmentations of the dorsum require different volume addition techniques. The choices for major dorsal augmentation rhinoplasty for Asian and African-American patients, for examples, is either that of a nasal implant or a rib cartilage graft. But any patient that needs more than a few millimeters of dorsal augmentation faces the same choices.

The emergence of injectable fillers has now allowed for a non-surgical rhinoplasty. The basic concept of a non-surgical rhinoplasty is that it can only add volume. Noses can become bigger with an injection technique but they can never become smaller. An injectable rhinoplasty can be used to trial what the augmented nose will look like but it will not be a permanent result. While there are some long lasting injectable fillers, placement of them into the nose carries some significant risk. But at the least injectable filler provides an instantaneous result and the opportunity for the patient to determine if this type of nasal enhancement is right for them.

Nasal implants offer a permanent method for dorsal nasal augmentation that does not require a harvest site. But it is an invasive procedure and requires the commitment to having a synthetic material in the nose. For this reason some patients may want tio have an injectable filler placed first.

An interesting questions is how does an injectable filler in the nose compared to a nasal implant? How does the volume of an injectable filler compared to the displacement effect caused by a solid implant?

Nasal Implants Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and nasal implants do) Using the most commonly used style of nasal implants for total dorsal augymentation (Rizzo nasal implants from Implantech) of all available sizes, their weights in grams and volume displacement were as follows:

NASAL IMPLANTS

Extra Small    0.96 grams    .7 ml

Small             1.14 grams     .8 ml

Medium         1.37 grams    1.1ml

Large             1.71 grams    1.5ml

Extra Large   1.95 grams    1.7 ml

Nasal Implant vs Radiesse Filler Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to nasal implants can be directly compared. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to small and medium sized styles of nasal implants. Larger nasal implants more directly compare to a 1.5cc syringe of Radiesse. (which weighs 1.7 grams)

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants. This may be particularly relevant in the nose where the nasal skin is less elastic and more firmly attached than other facial areas.

The use of 1 to 1.5cc of an injectable filler can compare volumetrically to that of an implant in the nose for more significant dorsal augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Volume Comparison of Cheek Implants and Injectable Fillers

Wednesday, June 1st, 2016

Cheek augmentation is a common facial reshaping procedure that is done for both aesthetic enhancement and volume restoration due to aging. It is the one facial procedure that, while historically only done with cheek implants, is now done more often by injection methods using synthetic fillers or fat.

The emergence of injectable methods is now the most common approach for cheek augmentation. Any of the synthetic fillers can be used since the cheek is a broad area and is spread out over the cheekbone as well as below it in the submalar region.While no synthetic injectable filler provides a permanent result, it does provide an instantaneous result and the opportunity for the patient to determine if this type of facial enhancement is appealing to them.

Cheek implants offer the only guaranteed permanent method  for cheek augmentation. But this requires a surgical commitment to an invasive procedure and has certain risks and complications. Injectable fillers can also be placed over a broader surface area greater than that which most cheek implants can.

An interesting but relevant issue when using injectable fillers for cheek augmentation is how do they compare volumetrically to that of cheek implants. To create an injectable cheek augmentation effect, what volume of injectable filler is needed to compare to what a cheek implant does? An injectable method is only a fair test in facial augmentation if similar volumes of material are placed that compares to what an implant does.

Conform Submalar Implants Dr Barry Eppley IndianapolisConform Midfacial Implant Dr Barry Eppley IndianapolisComparing facial implants and injectable fillers is done using volumetric displacement. Based on the Archimedes principle of displacement, volume of displaced water would equal to the volume of the implant. (provided that they sink in water and cheek implants do) Using the most commonly used style of cheek implants (Conform Submalar and Conform Malar Shells from Implantech) of all available sizes, their weights in grams and volume displacement were as follows:

SUBMALAR CHEEK IMPLANTS

Small        1.89 grams     0.7ml

Medium   2.13 grams     0.8ml

Large        2.36 grams     1.1ml

Large        2.58 grams     1.3ml

MALAR CHEEK IMPLANTS

Extra Small  1.47 grams   0.6ml

Small             1.71  grams   0.7ml

Medium        1.96 grams    0.8ml

Large              2.43 grams   1.1ml

Extra Large   2.62 grams   1.3 ml

Volume Displacement of Facial Implants Dr Barry Eppley IndianapolisThe volume displacement of all injectable fillers is on the syringe so the comparison to cheek implants can be directly compared. It shows that a 1cc syringe of any of the hyaluronic acid-based fillers (e.g., Juvederm) would be equal to small and medium sized styles of cheek implants.ess than even a small chin implant. Larger cheek implants more directly compare to a 1.5cc syringe of Radiesse.

Volume alone, however, is not the complete story of any material’s external facial augmentation effect. Besides volume there is the issue of how well the material pushes on the overlying soft tissues to create their effect. This is known as G Prime Force or the elastic modulus. By feel it is obvious that cheek implants are stiffer than any liquid material and would have a higher resistance to deformation. (thus creating more outward effect given a similar material volume) It is therefore probable that comparing volume displacements alone overestimates the effect of injectable fillers compared to implants.

The comparison between injectable fillers and implants in the cheeks may be different than in many other facial enhancement sites. Because the cheeks cover a significant soft tissue area not supported by bone the direct volumetric comparison may be more similar despite its lower elastic modulus.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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